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Penilaian yang objektif dengan menggunakan metode penerapan dan instrumen penilaian yang baku sangat diutamakan demi tercapainya pelayanan yang bermutu. Instrumen Evaluasi Penerapan Standar Asuhan Keperawatan ini terdiri dari (1) Pedoman Studi Dokumentasi Asuhan Keperawatan yang disebut Instrumen A, (2) Angket yang ditujukan kepada pasien dan keluarga untuk memperoleh gambaran tentang persepsi pasien terhadap mutu asuhan keperawatan yang disebut Instrumen B, (3) Pedoman Observasi Pelaksanaan Tindakan Keperawatan selanjutnya disebut Instrumen C. Ketiga instrumen ini satu sama lainnya saling terkait, dimana dua instrumen yang mullah dianalisis dan dinilai adalah instrumen A dan instrumen B. Kedua instrumen tersebut dapat dinilai melalui penelaahan. Untuk mengetahui perbedaan mutu asuhan keperawatan berdasarkan dokumentasi asuhan keperawatan dan persepsi pasien maka harus dilakukan penilaian mutu asuhan keperawatan di bagian rawat inap Siloam Hospital Lippo Karawaci. Disain penelitian ini adalah survei dengan rancangan cross sectional. Data kuantitatif diperoleh melalui dokumentasi asuhan keperawatan dalam bentuk cek list dan angket persepsi pasien. Instrumen yang digunakan merupakan modifikasi dari instrumen evaluasi penerapan standar asuhan keperawatan di rumah sakit yang telah diterbitkan oleh Departemen Kesehatan Republik Indonesia tahun 2005. Sampel sebanyak 98 dokumen asuhan keperawatan dan 98 pasien yang minimal telah dirawat selama 3 hari di Bagian Rawat Inap Siloam Hospital Lippo Karawaci. Hasil penelitian menunjukkan bahwa mutu asuhan keperawatan berdasarkan telaah dokumentasi asuhan keperawatan dapat dinilai dengan memberikan angketlkuisioner kepada pasien. Dan hasil analisis bivariat menunjukkan bahwa mutu asuhan keperawatan pada pendokumentasian asuhan keperawatan berdasarkan pengkajian, diagnosa, perencanaan, evaluasi dan catatan asuhan keperawatan dapat dinilai dengan memberikan angketlkuisioner kepada pasien. Namun metoda penilaian ini tidak dapat diterapkan pada aspek tindakan keperawatan. Adapun mute asuhan keperawatan berdasarkan telaah dokumentasi asuhan keperawatan dan telaah persepsi pasien menunjukkan tidak ada perbedaan yang bermakna dan masuk dalam kategori baik. Penilaian mutu asuhan keperawatan berdasarkan telaah persepsi pasien terbukti tidak ada perbedaan yang bermakna pada aspek pengkajian, diagnosa, perencanaan, evaluasi dan catatan asuhan keperawatan. Dan terbukti ada perbedaan yang bermakna pada aspek tindakan keperawatan. Persepsi pasien terhadap dokumentasi asuhan keperawatan masuk dalam kategori baik pada aspek pengkajian, diagnosa, perencanaan dan catatan asuhan keperawatan, sedangkan pada aspek tindakan dan evaluasi keperawatan masuk dalam kategori yang buruk. Berdasarkan hasil penelitian ini maka pihak manajemen Siloam Hospital Lippo Karawaci khususnya bagian keperawatan disarankan untuk melakukan penilaian mutu asuhan keperawatan terhadap aspek tindakan keperawatan melalui observasi dengan menggunakan instrumen C, sedangkan pada aspek evaluasi keperawatan agar tercapai mutu asuhan keperawatan yang berhasil guna sebaiknya dilakukan supervisi terhadap proses pendokumentasian asuhan keperawatan
Objective assessment by using applicable method and valid instrument assessment are really needed to reach a qualified service. The evaluation instrument for applicable nursing lead support standard are (1) studies catalog for nursing lead support assessment alias Instrument A, (2) quitioners for the patient and family to get the description of patient perception for nursing lead support quality alias Instrument B, (3) observation studies of the applicable of nursing action alias Instrument C. The instrument is connected to each other, the instrument A and Instrument B are the easy instrument to analyses and to make an assessment by seeing through. To know the different of nursing lead support quality based on nursing documentation lead support and patient perception, we should make an assessment for nursing lead support at inpatient department of Siloam Hospital Lippo Karawaci. The used design was a survey with cross sectional. And utilized method are quantitative and the data came from documentation of nursing lead support and patient perception quitionare. The used documentation was the modification from the standard of nursing lead support process evaluation instrument in the hospital, was issues from Healthcare Departement Republic of Indonesia in 2005. The sample research was 98 documentation of nursing Iead support, and the patient that cared minimal 3 days. The result indicated that the quality of nursing lead support based on see through documentation of nursing lead support are assess able by giving a quitionare to the patient. The bivariat analysis implied that the quality of nursing lead support was able to assess by nursing studies, nursing diagnose, nursing plan, nursing evaluation dan nursing lead support record based on documentation of nursing lead support by giving an quitionare to the patient. But the result indicated that the nursing act was dissable using this methode. Otherwise, the quality of nursing lead support based on see through nursing documentation lead support and see through the patient perception are showing un different meaning in the good category. The quality assessment of nursing lead support based on see through the patient perception are showing the different meaning in nursing studies, nursing diagnose, nursing plan, nursing evaluation and nursing lead support note. For there more, that in the nursing act are showing a different meaning. The patient perception by nursing documentation Iead support are in the good category in the aspect nursing studies, nursing diagnose, nursing plan and nursing lead support note, otherwise, in the nursing act aspect are in the worst category. Based on this research, are recommended to the Siloam Hospital Lippo Karawaci specially in nursing management, to reach the quality assessment in nursing lead support for nursing act aspect, to make an assessment better using the observation methode or using the instrument C, otherwise in the nursing evaluation aspect, to reach the applicable nursing quality lead support the nursing management should do the supervision in nursing documentation lead support process.
ABSTRAK Dokumen asuhan keperawatan sangat diperlukan untuk kepentingan pasien maupun perawat, akan tetapi pada kenyataannya kelengkapan dokumen masih banyak ditemukan yang isinya belum lengkap. Alasan dilakukan penelitian ini karena perawat memiliki persepsi yang berbeda – beda terhadap pelaksanaan dan penyebab ketidaklengkapan dokumen asuhan keperawatan tersebut. Penelitian ini bertujuan untuk menganalisis kelengkapan dokumen asuhan keperawatan, mendeskripsikan kaitan antara pengetahuan perawat, motivasi perawat dan supervisi atasan dengan kelengkapan dokumen asuhan keperawatan. Metode penelitian ini adalah studi kasus dengan pendekatan kualitatif. Teknik pengumpulan data dengan observasi dan wawancara mendalam. Hasil penelitian menunjukkan bahwa kelengkapan pengisian dokumen asuhan keperawatan didapatkan masih banyak yang kosong dan tidak lengkap. Aspek yang dinilai adalah pengkajian keperawatan, diagnosa keperawatan, rencana keperawatan, implementasi keperawatan, otentifikasi, resume keperawatan dan evaluasi keperawatan. Kesadaran perawat untuk melengkapi setiap bagian dokumen asuhan keperawatan masih kurang. Walaupun perawat sudah mempunyai pengetahuan mengenai dokumen asuhan keperawatan, namun ternyata belum ada motivasi karena kurangnya pengakuan, tanggung jawab dan pengembangan potensi individual. Selain itu, tidak ada supervisi dari atasan berupa pengarahan, bimbingan, observasi, dan evaluasi kepada perawat. Saran dari penelitian ini adalah bahwa kelengkapan dokumen di departemen rawat inap MRCCC Siloam Hospitals Semanggi harus menjadi perhatian pihak manajemen, selain itu disadari membutuhkan pelatihan teknis pengisian dokumen asuhan keperawatan serta memberikan reward dan punishment kepada perawat serta supervisi oleh kepala ruangan. Kata Kunci : kelengkapan dokumen, asuhan keperawatan, rumah sakit.
ABSTRACT Nursing care document is required for the benefit of patients and nurses. The fact, however, shows that there are a lot of incomplete nursing care documents. The research is carried out due to different perception as to the compliance and the causes of this incompleteness. The objective of this research is to analyze nursing care document completion. Spesific objectives are to describe the relationship between the nurses’s knowledge, motivation and supervision and nursing care document completion. This is a case-study in MRCCC Siloam Hospitals Semanggi using qualitative approach. Data collection techniques are observation and in-depth interview. The result showed that most of nursing care document were incomplete and empty. This component were nursing assessment, nursing diagnoses, nursing plan, nursing implementation, authentication, and evaluation of nursing resume. The nurses had low awareness on completing each of the document completion. Although the nurses understand nursing care document, they did not obtain sufficient motivation such as recognition, responsibility and personal potential development. In addition, there were lack of supervision, direction, guidance, observation and evaluation. It is suggested that MRCCC Siloam Hospitals Semanggi pay more attention on the document completion at the inpatient department. It is also suggested to organize trainings on how to fill out nursing care documents as well as improve motivation through reward and punishment schemes and supervision by the head nurse. Keywords: document completion, nursing care, hospital
Dokumentasi keperawatan merupakan bukti dari pelaksanaan keperawatan yang menggunakan metode proses keperawatan, berisi tentang catatan respon pasien terhadap tindakan medis dan tindakan keperawatan serta merupakan indikator mutu asuhan keperawatan. Agar pelayanan keperawatan berkualitas maka perawat diharapkan dapat menerapkan asuhan keperawatan dengan pendokumentasian yang benar.
Penelitian ini bertujuan untuk menganalisis kelengkapan dokumen asuhan keperawatan terkait dengan faktor individu, faktor organisasi dan faktor psikologis, menggunakan metode kualitatif dengan teknik pengumpulan data observasi dan wawancara mendalam. Observasi memungkinkan peneliti mengamati langsung tantangan perawat dalam melengkapi dokumen pengkajian, diagnosa keperawatan, rencana tindakan, implementasi, evaluasi dan catatan keperawatan.
Hasil penelitian menunjukkan bahwa secara umum pengisisan kelengkapan dokumentasi asuhan keperawatan di rumah sakit Santo Antonio masih di bawah standar Depkes. Perawat sudah menyadari pentingnya pendokumentasian asuhan keperawatan. Kendala yang dihadapi antara lain kurangnya tenaga dan kurangnya fasilitas yang ada seperti petunjuk teknis pengisian dokumentasi asuhan keperawatan. Selain itu, belum pernah dilakukan pelatihan terkait dengan pendokumentasian asuhan keperawatan. Perawat memanfaatkan hasil dokumentasi sebagai materi komunikasi kemajuan kondisi pasien, namun dokter belum memanfaatkan secara maksimal hasil dokumentasi yang dibuat oleh perawat.
Saran dari penelitian ini adalah agar pihak manajemen memenuhi jumlah tenaga, mengadakan pelatihan dan seminar, membuat petunjuk teknis pengisian dokumentasi asuhan keperawatan, menerapkan supervise berjenjang serta membuat lembar catatan pasien yang terintegrasi dari seluruh tenaga kesehatan. Saran untuk Kemenkes adalah mengembangkan peraturan yang memberikan pemisahan yang jelas antara tugas dokter dan tugas perawat.
Nursing documentation is an evidence of the implementation of nursing, using the nursing process method, which is contains the report of the patients’ response to the medical and nursing care also an indicator of the nursing care quality. In order to support the nursing care quality, the nurse should applied itself with proper documentation.
The aim of this research is to analyze the completion of the nursing care document, in relation to the individual, organizational, and psychological factors by using qualitative methods such as observation and in-depth interviews. This study is allow to observed nurses challenges to complete the document, diagnose, treatment planning, implementation, evaluation and medical record.
The study revealed that nursing care document completion in Saint Antonio hospital is still below standard even the nurses realized the importance of documenting nursing care. Challenges were found are the nurses work load, no technical guideline for completing the nursing document, no trainings and no workshops for the nurses. Nurses are going to use the results of the documentation to discuss the progress of patient’s condition, but clinicians do not use it as expected.
The study suggests the management to increase the number of personnel, to held trainings and seminars for nurses, to develop technical guideline for nursing documentation, to implement head nurse’s supervision and also create an integrated record sheet based on various personal’s health. Recommendation for Ministry of Health is to provide regulation of clear duty of nurses and doctors.
Providing health services requires quality resources to produce a good outcome. Thus, human resources should be viewed as assets and even hospital investments. Nurses who are the largest proportion of workforce in health services will contribute to the success of the service if they can perform their duties and functions according to standards. Nurses who have good ability and motivation will contribute to the task of administering hospital health services through nursing services. Conversely, nurses who do not perform nursing care properly and correctly can cause problems in patient care. Therefore, this research was conducted with the aim of looking at the relationship between the abilities, motivation and supervision of nurses on the completeness of nursing care documentation in the Imanuel Hospital Sumba ward. This study used a quantitative observational research design with cross-sectional data collection methods by observing or measuring each research variable once at a time. In this study, the research subjects were nurses at Imanuel General Hospital. Subjects were asked to fill out a questionnaire on ability, motivation and supervision. The scores for each questionnaire item are summed. A total score is 100%, a score of 65% or more is considered good, while a score less than 65 is considered insufficient. Of the 22 nurse respondents who served in the inpatient room of Imanuel Sumba Hospital, whose nursing care was then traced, there were 8 nurses (36.4%) whose complete nursing care was categorized as good, and the remaining 14 people (63.6%) had complete care. nursing is in a poor category. Nurses who have good knowledge 17 (77.3%) and less good 5 (22.7%). Nurses who have good skills are 16 (72.7%) and less good 6 (27.3%). Nurses with good motivation are 5 (22.7%) and less 17 (77.3%). Nurses who stated good supervision were 9 (40.9%) and less 13 (59.1%). There is no significant relationship between knowledge (p value = 0.613) and skills (p value = 0.624) with the completeness of nursing care. There is a significant relationship between motivation (p value = 0.039) and supervision (p value = 0.043) with the completeness of nursing care
Tujuan: Penelitian ini bertujuan untuk melakukan pengkajian berbagai faktor-faktor yang mempengaruhi kinerja perawat dalam melakukan dokumentasi asuhan keperawatan di Unit Rawat Inap RSU Bintang
Metode: Penelitian ini menggunakan pendekatan kuantitatif dengan analisis cross sectional yang dilakukan pada perawat di instalasi rawat inap RSU Bintang. Penelitian ini melakukan evaluasi terhadap hubungan dari motivasi, kepemimpinan kepala ruangan terhadap kinerja perawat dalam melakkukan pendokumentasian asuhan keperawatan.
Hasil: Penelitian ini menunjukkan bahwa terdapat hubungan antara asppek motivasi kerja yaitu persepsi peran (OR: 12,38; p=0,001), desain pekerjaan (OR: 8,72; p=0,002), kondisi kerja (OR: 29,2; p<0,001), dan pengebangan karir (OR: 7,31; p=0,005) terhadap kinerja perawat. Kemudian berdasarkan variabel kepemimpinan kepala ruangan, aspek kredibilitas (OR: 12,91; p<0,001) dan komunikasi (OR: 8,8; p=0,003) memiliki hubungan dengan kinerja perawat dalam melakukan dokumentasi. Melalui analisis multivariate ditemukan bahwa persepsi peran merupakan faktor yang paling berpengaruh dalam kinerja perawat dalam melakukan dokumentasi asuhan keperawatan (aOR: 19,2); p<0,05).
Simpulan: persepsi peran, desain pekerjaan, kondisi kerja, dan pengembangan karir, kredibilitas kepala ruangan, dan komunikasi kepala ruangan merupakan faktor motivasi yang mendukung untuk tercapainya kinerja perawat yang baik dalam melakukan pendokumentasian asuhan keperawatan di unit rawat inap RSU Bintang.
Background: One of the duties of a nurse is to provide nursing care. What is meant by nursing care is the elaboration of the target regarding the level of performance, the quality of the structure, the process of giving nursing care, to obtain a result which can then be assessed. In the Bintang Hospital itself the nurse's performance evaluation has not been done properly and correctly, and in random inspection there is always an incomplete medical record for nursing care, so this is a reflection of the lack of performance of nurses. On the other hand documentation is an indicator of hospital quality, so that it becomes a problem if documentation is not done completely and accurately.
Objective: This study aims to study various factors that influence the performance of nurses in conducting nursing care documentation in the Star Hospital RSU Inpatient Unit
Method: This study used a quantitative approach with cross sectional analysis carried out on nurses at the inpatient hospital of Bintang Hospital. This study evaluates the relationship of motivation, leadership of the head of the room to the performance of nurses in documenting nursing care.
Results: This study shows that there is a relationship between work motivation aspects, namely perceptions of role (OR: 12.38; p = 0.001), job design (OR: 8.72; p = 0.002), work conditions (OR: 29.2; p <0.001), and career development (OR: 7.31; p = 0.005) on nurse performance. Then based on head room leadership variables, aspects of credibility (OR: 12.91; p <0.001) and communication (OR: 8.8; p = 0.003) have a relationship with the performance of nurses in conducting documentation. Through multivariate analysis it was found that perceptions of role were the most influential factors in nurse performance in carrying out nursing care documentation (aOR: 19,2); p <0.05).
Conclusions: perceptions of roles, job design, working conditions, and career development, credibility of the head of the room, and communication of the head of the room are supporting motivational factors to achieve good nurse performance in documenting nursing care in the inpatient unit of Bintang Hospital.